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| ==[[Sudden death prognosis|Prognosis]]== | | ==[[Sudden death prognosis|Prognosis]]== |
| ==[[Sudden death post arrest care and prevention|Post arrest care and prevention]]== | | ==[[Sudden death post arrest care and prevention|Post arrest care and prevention]]== |
| ==[[Sudden death ethical issues|Ethical issues]] | | ==[[Sudden death ethical issues|Ethical issues]]== |
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| ==Prevention== | |
| With positive outcomes following cardiac arrest so unlikely, a great deal of effort has been spent in finding effective strategies to prevent cardiac arrest.
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| As noted above, one of the prime causes of cardiac arrest outside of hospital is [[ischemic heart disease]]. Vast resources have been put into trying to reduce cardiovascular risks across much of the developed world. In particular schemes have been put in place to promote a [[healthy diet]] and [[exercise]]. For people considered to be particularly at risk of heart disease, measures such as [[blood pressure]] control, prescription of [[cholesterol]] lowering medications, and other medico-therapeutic interventions, have been widely used. A [[magnesium deficiency (medicine)|magnesium deficiency]], or lower levels of [[magnesium]], can contribute to heart disease and a [[healthy diet]] that contains adequte [[magnesium]] may help prevent heart disease.<ref name="pmid15466951">{{cite journal |author=Rosanoff A, Seelig MS |title=Comparison of mechanism and functional effects of magnesium and statin pharmaceuticals |journal=J Am Coll Nutr |volume=23 |issue=5 |pages=501S–505S |year=2004 |month=October |pmid=15466951 |doi= |url=http://www.jacn.org/cgi/pmidlookup?view=long&pmid=15466951}}</ref> [[Magnesium]] can be used to enhance long term treatment, so it may be effective in long term prevention.<p>
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| Patients in hospital are far less likely to have a cardiac arrest caused of primary cardiac origin, and hence present in Asystole or PEA, and have bleak outcomes. Extensive research has shown that patients in general wards often deteriorate for several hours or even days before a cardiac arrest occurs <ref name="pmid15325446">{{cite journal |author=Kause J, Smith G, Prytherch D, Parr M, Flabouris A, Hillman K |title=A comparison of antecedents to cardiac arrests, deaths and emergency intensive care admissions in Australia and New Zealand, and the United Kingdom--the ACADEMIA study |journal=Resuscitation |volume=62 |issue=3 |pages=275–82 |year=2004 |month=September |pmid=15325446 |doi=10.1016/j.resuscitation.2004.05.016 |url=}}</ref>. This has been attributed to a lack of knowledge and skill amongst ward based staff, in particular a failure to carry out measurement of the [[Respiratory rate]], which is often the major predictor of a deterioration and can often change up to 48 hours prior to a cardiac arrest. In response to this, many hospitals now have increased training for ward based staff. A number of "early warning" systems also exist which aim to quantify the risk which patients are at of deterioration based on their [[vital signs]] and thus provide a guide to staff. In addition, specialist staff are being utilised more effectively in order to augment the work already being done at ward level. These include:
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| * '''Crash teams''' (also known as '''Code teams''') - These are designated staff members who have particular expertise in resuscitation, who are called to the scene of all arrests within the hospital.
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| * '''Medical Emergency Teams''' - These teams respond to all emergencies, with the aim of treating the patient in the acute phase of their illness in order to prevent a cardiac arrest.
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| * '''Critical care outreach''' - As well as providing the services of the other two types of team, these teams are also responsible for educating non-specialist staff. In addition, they help to facilitate transfers between [[Intensive care unit|intensive care/high dependency units]] and the general hospital wards. This is particularly important, as many studies have shown that a significant percentage of patients discharged from critical care environments quickly deteriorate and are re-admitted - the outreach team offers support to ward staff to prevent this from happening.
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| ==Implantable cardioverter defibrillators==
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| A technically based intervention to prevent further cardiac arrest episodes is the use of an '''[[implantable cardioverter-defibrillator]]''' (ICD). This device is implanted in to the patient and can offer a 'pacemaker' effect to the heart as well as acting as an instant defibrillator in the event of arrhythmia. A recent study by Birnie et al at the University of Ottawa Heart Institute has demonstrated that ICDs are underused in both the United States and Canada.<ref name="pmid17606938">{{cite journal |author=Birnie DH, Sambell C, Johansen H, ''et al'' |title=Use of implantable cardioverter defibrillators in Canadian and US survivors of out-of-hospital cardiac arrest |journal=CMAJ |volume=177 |issue=1 |pages=41–6 |year=2007 |month=July |pmid=17606938 |pmc=1896034 |doi=10.1503/cmaj.060730 |url=}}</ref> An accompanying editorial by Simpson explores some of the economic, geographic, social and political reasons for this.<ref name="pmid17606939">{{cite journal |author=Simpson CS |title=Implantable cardioverter defibrillators work--so why aren't we using them? |journal=CMAJ |volume=177 |issue=1 |pages=49–51 |year=2007 |month=July |pmid=17606939 |pmc=1896028 |doi=10.1503/cmaj.070470 |url=}}</ref>
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| ==Prevention of Sudden Cardiac Death==
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| ===ACC / AHA Guidelines- Recommendations for Implantable Cardioverter Defibrillators (DO NOT EDIT) <ref name="pmid18483207">{{cite journal |author=Epstein AE, DiMarco JP, Ellenbogen KA, ''et al'' |title=ACC/AHA/HRS 2008 Guidelines for Device-Based Therapy of Cardiac Rhythm Abnormalities: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the ACC/AHA/NASPE 2002 Guideline Update for Implantation of Cardiac Pacemakers and Antiarrhythmia Devices): developed in collaboration with the American Association for Thoracic Surgery and Society of Thoracic Surgeons |journal=Circulation |volume=117 |issue=21 |pages=e350-408 |year=2008 |month=May |pmid=18483207 |doi:10.1161/CIRCUALTIONAHA.108.189742 |url=}}</ref>===
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| {{cquote|
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| ===Class I===
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| 1. [[ICD therapy]] is indicated in patients who are survivors of [[cardiac arrest]] due to [[VF]] or hemodynamically unstable sustained [[VT]] after evaluation to define the cause of the event and to exclude any completely reversible causes. (Level of Evidence: A)
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| 2. [[ICD therapy]] is indicated in patients with structural [[heart disease]] and spontaneous sustained [[VT]], whether hemodynamically stable or unstable. (Level of Evidence: B)
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| 3. [[ICD therapy]] is indicated in patients with [[syncope]] of undetermined origin with clinically relevant, hemodynamically significant sustained [[VT]] or [[VF]] induced at electrophysiological study. (Level of Evidence: B)
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| 4. [[ICD therapy]] is indicated in patients with [[LVEF]] less than 35% due to prior [[MI]] who are at least 40 days post-MI and are in NYHA functional Class II or III. (Level of Evidence: A)
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| 5. [[ICD therapy]] is indicated in patients with [[nonischemic DCM]] who have an [[LVEF]] less than or equal to 35% and who are in NYHA functional Class II or III. (Level of Evidence: B)
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| 6. [[ICD therapy]] is indicated in patients with [[LV dysfunction]] due to prior [[MI]] who are at least 40 days post-MI, have an [[LVEF]] less than 30%, and are in NYHA functional Class I. (Level of Evidence: A)
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| 7. [[ICD therapy]] is indicated in patients with [[nonsustained VT]] due to prior [[MI]], [[LVEF]] less than 40%, and [[inducible VF]] or [[sustained VT]] at electrophysiological study. (Level of Evidence: B)
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| ===Class IIa===
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| 1. [[ICD implantation]] is reasonable for patients with unexplained [[syncope]], significant [[LV dysfunction]], and [[nonischemic DCM]]. (Level of Evidence: C)
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| 2. [[ICD implantation]] is reasonable for patients with [[sustained VT]] and normal or near-normal [[ventricular function]]. (Level of Evidence: C)
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| 3. [[ICD implantation]] is reasonable for patients with [[HCM]] who have 1 or more major{dagger} risk factors for [[SCD]]. (Level of Evidence: C)
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| 4. [[ICD implantation]] is reasonable for the prevention of [[SCD]] in patients with [[ARVD/C]] who have 1 or more risk factors for [[SCD]]. (Level of Evidence: C)
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| 5. [[ICD implantation]] is reasonable to reduce [[SCD]] in patients with [[long-QT syndrome]] who are experiencing [[syncope]] and/or [[VT]] while receiving [[beta blockers]]. (Level of Evidence: B)
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| 6. [[ICD implantation]] is reasonable for non hospitalized patients awaiting [[transplant]]ation. (Level of Evidence: C)
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| 7. [[ICD implantation]] is reasonable for patients with [[Brugada syndrome]] who have had [[syncope]]. (Level of Evidence: C)
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| 8. [[ICD implantation]] is reasonable for patients with [[Brugada syndrome]] who have documented [[VT]] that has not resulted in [[cardiac arrest]]. (Level of Evidence: C)
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| 9. [[ICD implantation]] is reasonable for patients with [[catecholaminergic polymorphic VT]] who have syncope and/or documented sustained [[VT]] while receiving [[beta blockers]]. (Level of Evidence: C)
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| 10. [[ICD implantation]] is reasonable for patients with [[cardiac sarcoidosis]], [[giant cell myocarditis]], or [[Chagas disease]]. (Level of Evidence: C)
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| ===Class IIb===
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| 1. [[ICD therapy]] may be considered in patients with nonischemic [[heart disease]] who have an [[LVEF]] of less than or equal to 35% and who are in NYHA functional Class I. (Level of Evidence: C)
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| 2. [[ICD therapy]] may be considered for patients with [[long-QT syndrome]] and risk factors for [[SCD]]. (Level of Evidence: B)
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| 3. [[ICD therapy]] may be considered in patients with [[syncope]] and advanced structural heart disease in whom thorough invasive and noninvasive investigations have failed to define a cause. (Level of Evidence: C)
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| 4. [[ICD therapy]] may be considered in patients with a [[familial cardiomyopathy]] associated with sudden death. (Level of Evidence: C)
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| 5. [[ICD therapy]] may be considered in patients with [[LV]] noncompaction. (Level of Evidence: C)
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| ===Class III===
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| 1. [[ICD therapy]] is not indicated for patients who do not have a reasonable expectation of survival with an acceptable functional status for at least 1 year, even if they meet [[ICD implantation]] criteria specified in the Class I, IIa, and IIb recommendations above. (Level of Evidence: C)
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| 2. [[ICD therapy]] is not indicated for patients with incessant [[VT]] or [[VF]]. (Level of Evidence: C)
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| 3. [[ICD therapy]] is not indicated in patients with significant [[psychiatric illness]]es that may be aggravated by device implantation or that may preclude systematic follow-up. (Level of Evidence: C)
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| 4. [[ICD therapy]] is not indicated for NYHA Class IV patients with [[drug-refractory congestive heart failure]] who are not candidates for [[cardiac transplantation]] or [[CRT-D]]. (Level of Evidence: C)
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| 5. [[ICD therapy]] is not indicated for [[syncope]] of undetermined cause in a patient without [[inducible ventricular tachyarrhythmias]] and without structural [[heart disease]]. (Level of Evidence: C)
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| 6. [[ICD therapy]] is not indicated when [[VF]] or [[VT]] is amenable to surgical or catheter ablation (e.g., [[atrial arrhythmias]] associated with the [[Wolff-Parkinson-White syndrome]], [[RV]] or [[LV]] [[outflow tract VT]], [[idiopathic VT]], or [[fascicular VT]] in the absence of structural [[heart disease]]). (Level of Evidence: C)
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| 7. [[ICD therapy]] is not indicated for patients with [[ventricular tachyarrhythmias]] due to a completely reversible disorder in the absence of structural [[heart disease]] (e.g., [[electrolyte imbalance]], [[drugs]], or [[trauma]]). (Level of Evidence: B)}}
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| ===ACC / AHA Guidelines- Recommendations for Implantable Cardioverter-Defibrillators in Pediatric Patients and Patients With Congenital Heart Disease (DO NOT EDIT) <ref name="pmid18483207">{{cite journal |author=Epstein AE, DiMarco JP, Ellenbogen KA, ''et al'' |title=ACC/AHA/HRS 2008 Guidelines for Device-Based Therapy of Cardiac Rhythm Abnormalities: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the ACC/AHA/NASPE 2002 Guideline Update for Implantation of Cardiac Pacemakers and Antiarrhythmia Devices): developed in collaboration with the American Association for Thoracic Surgery and Society of Thoracic Surgeons |journal=Circulation |volume=117 |issue=21 |pages=e350-408 |year=2008 |month=May |pmid=18483207 |doi:10.1161/CIRCUALTIONAHA.108.189742 |url=}}</ref>===
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| {{cquote|
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| ===Class I===
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| 1. [[ICD implantation]] is indicated in the survivor of [[cardiac arrest]] after evaluation to define the cause of the event and to exclude any reversible causes. (Level of Evidence: B)
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| 2. [[ICD implantation]] is indicated for patients with [[symptomatic sustained VT]] in association with [[congenital heart disease]] who have undergone hemodynamic and electrophysiological evaluation. [[Catheter ablation]] or surgical repair may offer possible alternatives in carefully selected patients. (Level of Evidence: C)
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| ===Class IIa===
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| 1. [[ICD implantation]] is reasonable for patients with [[congenital heart disease]] with [[recurrent syncope]] of undetermined origin in the presence of either [[ventricular dysfunction]] or [[inducible ventricular arrhythmia]]s at electrophysiological study. (Level of Evidence: B)
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| ===Class IIb===
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| 1. [[ICD implantation]] may be considered for patients with [[recurrent syncope]] associated with complex [[congenital heart disease]] and [[advanced systemic ventricular dysfunction]] when thorough invasive and noninvasive investigations have failed to define a cause. (Level of Evidence: C)
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| ===Class III===
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| 1. All Class III recommendations found in Section 3, "Indications for Implantable Cardioverter-Defibrillator Therapy," apply to pediatric patients and patients with [[congenital heart disease]], and [[ICD implantation]] is not indicated in these patient populations. (Level of Evidence: C) }}
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| ==Cardiac Arrest: Ethical Issues== | | ==Cardiac Arrest: Ethical Issues== |
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| Some people with a [[terminal illness]] choose to avoid such measures and die peacefully. People with views on the treatment they wish to receive in the event of a cardiac arrest should discuss these views with both their [[physician|doctor]] and with their family. A patient may ask their doctor to record a [[do not resuscitate]] (DNR) order in the medical record. Alternatively, in many jurisdictions, a person may formally state their wishes in an advance directive or [[advance health directive]]. | | Some people with a [[terminal illness]] choose to avoid such measures and die peacefully. People with views on the treatment they wish to receive in the event of a cardiac arrest should discuss these views with both their [[physician|doctor]] and with their family. A patient may ask their doctor to record a [[do not resuscitate]] (DNR) order in the medical record. Alternatively, in many jurisdictions, a person may formally state their wishes in an advance directive or [[advance health directive]]. |
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| ==See also== | | ==See also== |